There is no shortage of very strong opinions about children taking psychiatric medications. It seems that every media outlet has something inflammatory to say about psychiatrists who prescribe medications such as stimulants, anti-depressants, and mood stabilizers to children and adolescents. Often, in these news stories, there are very important voices missing – the voices of parents and children whose lives have been dramatically improved because of successful treatment with such medications. This issue is far too complex to boil down to a simple question of whether psychiatric medications should be used with children or not. Every decision to treat a child or adolescent with psychiatric medication requires comprehensive evaluation and consideration of many complex factors.
I am a psychologist, so I do not prescribe medication. I do, however, work very closely with some wonderful child psychiatrists, and I often refer child and adolescent clients to them to determine whether medication would be of benefit. I never do this lightly; I only make such a referral under the following circumstances:
- A child’s symptoms are creating significant interference with one or more important areas of functioning such as academic, social, or behavioral as in the example of a high school junior experiencing frequent panic attacks that make it very difficult for her to be in school
- A child is experiencing psychotic symptoms such as in the example of a young adolescent who hears voices commanding him to harm himself or others
- A child is experiencing a moderate to severe episode of mood disturbance with suicidal thoughts or behaviors such as in the example of a middle-schooler who is so depressed she cannot concentrate, is sleeping 14 hours a day, expresses feelings of hopelessness, and frequently thinks about swallowing a handful of pills from her parents’ medicine cabinet
- A child with less severe symptoms than those in the earlier examples has not experienced meaningful improvement after a course of therapy lasting 4-6 months such as in the example of a ninth grader with Social Anxiety Disorder who has not been able to make any friends after a full semester in a new school despite weekly cognitive-behavioral therapy
When families are faced with the difficult decision about the use of psychiatric medication for a child or adolescent, there is a tendency for parents to focus solely on the risks and benefits of the medication, to weigh the risks of side effects against the benefits of symptom reduction. While this is certainly an essential part of the decision-making process, I think there is a far more important risk-benefit analysis to consider: the risks and benefits of leaving the condition untreated.
By way of illustration, I have two stories to share from my practice, memorable because of the young people involved and because of the powerful lessons I learned from my work with them.
Years ago, I met a lovely and brilliant young man who was in his second year at an academically challenging K-12 school. He had entered the school in 8th grade and had had a somewhat disappointing first year grade-wise. In 9th grade, he was having a tremendously difficult time, earning C’s and D’s in most of his major subjects on his first report card. When I met Cory and his parents, there was a great deal of strain in the parent-child relationships and Cory was feeling pretty miserable. According to his parents, Cory had always been a good student. They were blaming his poor grades on their son’s “laziness” and on the teachers in the new school.
I suspected that Cory had Attention Deficit-Hyperactivity Disorder (ADHD) within the first several minutes of meeting him. He was physically restless and verbally impulsive. He lost his train of thought while answering my questions and occasionally interrupted his own comments to make random observations such as “Wow, look at those clouds.” I remember having a gut feeling that he and his parents were withholding important information; it turned out that I was right. After a thorough evaluation, which included psychoeducational testing, observational questionnaires from both parents and several teachers, and extensive interviews with Cory and his parents, I was confident that Cory did, in fact, have ADHD and that the demands of high school were too great to allow him to get by on brains alone. As soon as I shared my findings with the family, Cory turned to his parents and said angrily
None of this would have happened if you had just let me take the medicine when it was recommended. This is your fault, not mine! Cory, age 15
It turned out that I was just one in a series of mental health professionals that had evaluated Cory and made a diagnosis of ADHD. In fact, the first diagnosis was made when Cory was in 3rd grade and having behavioral problems. Mom and Dad were so resistant to both the diagnosis and the idea of medication that they had continued to seek new opinions for years.
Because Cory was over the age of consent for psychiatric treatment in the state of Pennsylvania, I explained to him that if he wanted to pursue a medication trial, he did not need his parents’ permission. Practically speaking, he really did need their support since he had to use their health insurance and he had no way to get to a pharmacy to fill a prescription. Following some persuasive arguments from their son which I fully supported, Mom and Dad relented, and Cory finally was able to receive appropriate treatment. The last I heard, which was years ago, Cory was attending a highly selective university pursuing a degree in bio-medical engineering.
Around the time I worked with Cory and his family, I evaluated a high school senior who was brought to see me because of tics (involuntary movements) and inattention. Like Cory, Aviva had also been evaluated before; she willingly disclosed that since elementary school, she had known that she had a primarily inattentive form of ADHD and Tourette Syndrome (TS) (learn more about TS here). For years, her mother had encouraged Aviva to take medication to improve focus and decrease tics. After a couple of unpleasant experiences with psychiatric medication side effects, Aviva had decided to manage her inattention with behavioral strategies and to accept that the tics were just a part of her she would have to embrace along with her other quirks.
When I asked Aviva and her mother why they had decided to come to therapy at this particular time, Mom talked about her worries that Aviva’s inattention would create greater academic difficulty at the college level and that the new peers she would meet in college would be less accepting of the tics than the friends she grew up with. To which, Aviva replied
So I should take medication to treat your worries? That makes no sense. – Aviva, age 18
After a few sessions, Mom agreed to honor her daughter’s wishes by not pressuring her to take medication and Aviva agreed to be open to the idea of medication down the road if the symptoms interfered with her social and/or academic functioning in college. A few years later, I saw Aviva’s younger brother for therapy, and I learned from him that his sister did very well in college and was pursuing an advanced degree in creative writing at an Ivy League school.
In both of these instances, I fully supported my clients’ decisions regarding medication. Cory’s academic achievement was falling far short of his ability due to interference from inattention and distractibility. The risks of leaving the ADHD symptoms untreated far outweighed the risks of the stimulant medication. For Cory, the stimulant turned out to be highly effective.
Aviva, in contrast, had tried medications that had unacceptable side effects for her. She had learned to cope with her short attention span and easy distractibility by creating structure in her schedule and creating environments that minimized distractions. And because Aviva was an unusually self-confident individual, she had accepted the tics and the social challenges they created at a fairly young age. Since there was no interference with her social or academic functioning, there was simply no reason to encourage use of medications. For Aviva, the risks of medication were greater than the risks of leaving the symptoms untreated.
Good parents, for all the right reasons, will struggle with the decision about psychiatric medication for a child. They should struggle; this is not a decision to be made lightly. It is essential to keep the decision-making process open and complex and to include the voice of the child. Nothing is gained by refusal to consider all of the complexities – the risks and benefits of medication as well as the risks and benefits of leaving a condition untreated. In a subsequent post, I will share with parents some questions that can be helpful in making this tough call.